August 2007 | Back to Table of Contents

Clinical and Health Affairs

A Culturally Appropriate, Student-Centered Curriculum on Medical Professionalism 

Successful Innovations at Keio University in Tokyo

By Gregory A. Plotnikoff, M.D., M.T.S., with Takahiro Amano, M.D.

Abstract
Professionalism is a Western concept without a precise equivalent in Asian cultures. The term itself cannot be translated directly into any Asian language, nor does the spectrum of words based on the verb “to profess” exist in any Asian language. In addition, the foundational assumptions found in the West’s celebrated Charter on Medical Professionalism do not match Asian ways of thinking regarding autonomy, service, and justice. Finally, there is no tradition in Asia of reciting an oath at medical school graduations. Despite the fact that professionalism is literally a foreign concept in Asia, Keio University School of Medicine in Tokyo has successfully introduced a professionalism curriculum that both supports Japan’s cultural traditions and affirms the school’s academic mission. This article describes a series of educational events for medical students in the university’s 6-year undergraduate program. These include development of a course on medical professionalism for students in their third year, a year-long extracurricular oath-writing project for fourth-year students, introduction of a White Coat Ceremony at the start of the fifth year (when students begin their clinical rotations), and a reflective writing requirement for sixth-year students on professionalism and humanism as witnessed during clinical rotations.

Being asked to teach professionalism would be a tall order for any physician. But for an American physician teaching in a Japanese medical school, imparting such lessons is an even greater challenge. In 2005, no such courses existed in Japan and quite possibly in all of Asia. That same year, the dean of the Keio University School of Medicine in Tokyo asked me to incorporate professionalism into the curriculum for medical students. In addition to there not being courses to draw from, I learned that the spectrum of terms found in English (profess, professor, profession, professional, professionalism) do not exist in any Asian language. Literal translations of the term “professionalism” are wildly inaccurate. Not only do the equivalent words not exist, neither does the background required to understand the concept. Foundational concepts of medical professionalism in the West such as patient autonomy, justice, and service are understood quite differently in the East, where the more than 2,000-year-old Confucian tradition gives priority to collectivist, authoritarian, and hierarchical cultural standards.

Furthermore, in Japan, as in all of Asia, there has never been a history of taking any medical oath; that is to say, there has never been a statement of ethical beliefs or commitments to “profess” at graduation. At Keio in 2004, only a small percentage of medical students had ever heard of the Hippocratic Oath. And an even smaller percentage could identify content from any medical oath.

Thus, I faced a dilemma. Professionalism might be viewed as a Western concept that had little connection with Japanese thinking. And, as a Western physician, anything I promulgated might be rejected as foreign. How could anyone successfully introduce the topic into such a hostile context?

I found the answer in an elective course for third-year students. In Japan, medical students go through 6 years of training that begin after they graduate from high school. During the first 4 years, they spend their time in the classroom studying basic science topics such as anatomy and pathophysiology. Starting in the fifth year, they see patients on the hospital wards. Given my extremely limited capacity for speaking Japanese at length or with sophisticated nuance, I improvised and developed an approach that I termed “teach the teacher,” changing my role from professor as lecturer to professor as facilitator. I admitted my ignorance and asked the students to answer the questions: What is a good doctor? What is a bad doctor? and How do you know the difference? To understand their reasoning, I also asked about the sources of their answers—the images, the stories, the myths, the metaphors in Japanese culture that guide their understanding. “Please teach me,” I asked the students.

Those questions initiated a dialogue about themes that were explored in greater depth as the course progressed. The first session included an overview of Western thinking found in the Hippocratic Oath and a review of the perceived importance of the act of “professing” the values that would guide future actions. From such a brief introduction, the students were responsible for generating the remainder of the course’s content.

Their first task as student teachers was to identify sources such as movies and stories that helped them answer my questions. The class then broke into 3 small groups. Each group was asked to examine a source, and in the following weeks, present the lessons on professionalism it contained.

The sources chosen by the first class were the Kurosawa film Akahige (Red Beard), the manga (a sophisticated Japanese comic book) Black Jack, and the Hollywood film Patch Adams. Surprisingly, the portrayals of physicians in these works seemed at odds with Japanese culture. Each physician seemed to be a force that disrupted the social harmony. But such foils generated much material for discussion. And, with each week, the students expanded their list of characteristics of a good and bad doctor.

To conclude the course, the students had to do 2 projects. First, they were to write a letter to themselves detailing why they had worked so hard to be where they were, why they wanted to be a doctor, and how they will know that they are a good doctor in the future. These letters were sealed and will be returned at their graduation.

Second, the students had to prepare their own personal oath. They could work in pairs to share ideas, but they needed to write a statement that would summarize what they learned and their reflections on it. These were then read out loud to the class.

This approach to learning was new but certainly was not rejected as being “foreign,” even from the very beginning of the class. The anonymous student evaluations of the course were extremely positive: averaging 4.75 on a scale of 1 to 5, with 5 being the top score.

Asia’s First White Coat Ceremony
In 2005, Keio University held the first Gold Foundation–funded White Coat Ceremony in Asia. Although White Coat ceremonies have been extremely popular in North America since their introduction in 1996, they were unheard of in Asia. The transition from the fourth to the fifth year at Keio when students moved from classroom to hospital/clinic-based learning was identified as being the best time to celebrate and honor the importance of humanism in medicine. With founders Arnold P. Gold, M.D., and his wife, Sandra, present for the event, students received their white coats from the dean and key faculty (Figure).

Although the students didn’t recite an oath during the ceremony, Takahiro Amano, M.D., professor of neurology and director of Keio’s medical education center, described their role, including that of the Hippocratic Oath, in medical history. Comparisons were made with other Japanese ceremonies, and the ceremony provided a forum for the dean and key faculty to set expectations for ethical and humanistic behavior in clinical settings.

The Student Oath Project
Given the absence of a domestic oath to recite, graduates of the professionalism course led a year-long project to produce one in time for the second annual White Coat Ceremony. This was a noncredit, extracurricular, student-led project that involved minimal input from faculty. Five groups worked simultaneously under the direction of 2 class leaders. All of the students demonstrated a strong commitment to the success of this project, with more than 95% of the class staying after their last exam to revise and ratify the final statement.

With ongoing curricular and extracurricular professionalism activities in the third, fourth, and fifth years, Keio faculty are now developing a reflective program that sixth-year students will teach to first- and fourth-year students. Before their graduation, the senior students will each be required to produce a statement reflecting on professionalism in action—or not in action—that they have witnessed during their clinical rotations. Professionalism will include those aspects of medical humanism that enhance patient care as well as those of interprofessional behavior that contribute to strong teamwork.

Conclusion
At Keio University School of Medicine, we are teaching professionalism using a sequential, overlapping, student-centered approach that is incorporated into the formal curriculum and extracurricular activities. Although efforts to instill professionalism are focused on students in their final 4 years of medical school, in the near future, activities will be incorporated into the first- and second-year curriculum. The extremely positive response we’ve received since starting this initiative demonstrates that even in a culture unfamiliar with the concept of medical professionalism, it can be taught in a way that is appreciated by students and faculty. MM

Gregory A. Plotnikoff is an associate professor at Keio University in Tokyo. Takahiro Amano, M.D., is a professor of neurology and director of Keio University’s medical education center.

Establishing the professionalism program at Keio University could not have been accomplished without the helpful input of Yasuo Ikeda, dean; Sadakazu Aiso, vice dean; Keisuke Kouyama, associate professor of pharmacology; Yuuki Sekiguchi, associate professor of pediatrics; and Kenji Watanabe, associate professor, Kampo medicine.